RIF pain Flashcards
Differentials for RIF pain
Appendicitis Gastroenteritis Uteric colic Inguinal hernia (encarcerated or strangulated) Epididymitis and/or orchitis Mesenteric adenitis Acute pancreatitis Testicular torsion Meckel's diverticulitis Cholecystitis Pyelonephritis Psoas abscess Bowel obstruction Constipation DKA
What differentials should be considered for females with RIF
Ectopic pregnancy Pelvic inflammatory disease/salpingitis Torsion/haemorrhoage/rupture of ovarian tumour or cyst Mittelschmerz Threatened abortion Fibroid degeneration
What should be looked for on examination
Signs of being ill - febrile, tachycardic, hypotensive, tachypnoeic Scars Abdominal distension Cervical lymphadenopathy (rule out mesenteric adenitis) Masses Bowel sounds Hernias Rectal exam External genitalia (testicular torsion)
What blood tests should be done for RIF
FBC: inflammation
CRP: inflammation
VBG: raised lactate, met. acidosos -> ischaemia or sepsis
U+Es: indication for fluids + prognosis
Serum amylase/lipase: mainly pancreatitis
Glucose: DKA + glasgow scoring
Liver enzymes: prognosis for pacnreatitis
How may a urinalysis be beneficial for RIF pain
Infection, renal/uteric calculi/retrocaecal appendix - haematuria
DKA - glucose, ketones
UTI - positive leucocyte esterase and nitrites
What imaging would be requested for RIF pain
Abdominal USS: renal/biliary pathology, appendicitis, free fluid, gynae problems
Erect CXR: pneumoperitoneum
CT abdomen:
ECG: ? sinus tachy
AXR: bowel obstruction, IBD + toxic megacolon, foreign body
What may cause a perforated viscus and pneumoperitoneum
Perforated peptic ulcer
Meckel’s diverticulum
Caecal diverticulum
Appendix
What are the typical features of mesenteric adenitis
Typically follows an URTI or sore throat Cervical lymphadenopathy may be present Common <15 yrs Pain often diffuse, uncommon to have peritonitis Fever often has a higher temperature
What are the typical features of Meckel’s diverticulitis
Almost identical to appendicitis
What are the typical features of constipation
Hx of infrequent/or absent bowel motions
Does not result in fever or tachycardia
What are the typical features of Crohn’s
Hx of diarrhoea and weight loss for week/months up to presentation, which is similar to appendicitis
What are the typical features of Gastroenteritis
Vomiting and diarrhoea main symptoms
Symptoms seen in close contacts
What are the typical features of Renal/uteric colic
Writhing in pain and would not migrate
Urine dipstick shows haematuria
What are the typical features of pancreatitis
Migration atypical and often pain in the epigastric region
Elevated amylase
How is acute appendicitis managed
IV fluid bolus Analgesia NBM Broad spectrum Abx DVT prophylaxis e.g. LMWH and Ted stockings Arrange appendicectomy
What is the sepsis 6
Take: lactate, Blood cultures, urine output (for AKI)
Give: high flow oxygen, IV antibiotics, fluid
What is appendix mass and how does it present
Greater omentum, caecum and/or adherent loops of small bowel wrap around the inflamed appendix
Presents like appendicitis but slightly milder pain
What is mittelschmertz syndrome
Affects 1 in 5 menstruating women
Relatively mild RIF pain, short-lived and cyclical in nature
Episodes are on different sides each time
Absence of signs on abdominal exam
What is the difference between SIRS, sepsis, severe sepsis , septic shock and multiorgan failure
Severe inflammatory response syndrome: temp >38 or <36, HR >90, RR >20 or pCO2 <4.3, WCC >12 or <4
Sepsis: SIRS caused by suspected infection
Severe sepsis: sepsis that causes hypotensions and end organ hypoperfusion
Septic shock: severe sepsis that is refractory to fluid resus
Multiorgan dysfunction/failure: evidence of two or more organs failing
What are the two incisions used for open appendicectomy
Gridiron incision - perpendicular to line between ASIS and umbilicus over Mcburney’s
Lanz - 2cm medial to the ASIS and follows a horizontal course (better cosmesis due to placement in natural skin crease)
Why does a surgeon inspect the distal 60cm of the terminal ileum during an operation where a normal appendix is found
Check for inflamed/rupture Meckel’s diverticulum
Remnant of the vitelline duct
Occurs in 2% of the population, may contain 2 types of ectopic cells (pancreatic and gastric), situated within 2 feet of the ileocaecal valve